This week, President Trump plans to declare the opioid epidemic a national emergency. It’s a welcome, but belated, response to a problem that has been growing inexorably for nearly two decades. For all the coverage the opioid epidemic has received, the reaction to it has been consistently muted. No group of activists quite as angry and eloquent as act up has emerged to make the crisis an urgent priority.

A family mourns the death of their son, Brian Malmsbury, who overdosed on heroin in the basement of their home. From left to right: Brian’s half sister, Brittany Neff; Brian’s stepfather, Damian Neff; and Brian’s mother, Patty Neff.

Opioids now kill more than fifty thousand Americans a year, ten thousand more than aids did at the peak of that epidemic—more, too, than gun homicides and motor-vehicle accidents. Opioid overdoses are now the leading cause of death for Americans under the age of fifty. Here, Narcan, which blocks the effects of opioids, is administered to a man overdosing on heroin.

Something about the nature of this epidemic delayed the sense of calamity. As the coroner of Montgomery County, Ohio, has said, it’s a “mass-casualty event,” but one played out in slow motion. First, in the nineteen-nineties, came mounting overdose deaths from prescription drugs such as OxyContin; then, around 2000, many users switched to heroin, a cheaper alternative; in the past few years, people increasingly have been dying from potent synthetic painkillers such as fentanyl and carfentanil. The quietness of the tragedy is also connected to the effects of opioids themselves: people hooked on them numb their pain, whatever its causes, rather than raging against it.

A homeless, heroin-addicted woman in Montgomery County. At the time the photograph was taken, she had been clean for nineteen days.

In Hamilton, a town nestled in the southwestern corner of Ohio, addicts meet at a center run by Sojourner Recovery Services. Outpatient clients attend group therapy up to five times per week.

In places hit hard by the epidemic—in Midwestern and New England towns where heroin used to seem like somebody else’s problem—overdose deaths now permeate everyday life, and have become impossible to ignore.

An abandoned, bedbug-infested home in Dayton, where people often go to do drugs. There are more than five thousand vacant homes in the city.

In Drexel, Deputy Andy Teague arrests a man for possession of heroin and crystal methamphetamine.

Phil Plummer, the sheriff of Montgomery County, responds to an overdose call in North Dayton at 1:52 P.M. According to Plummer, the peak time for overdose calls is 6 P.M.

In Montgomery County, the number of drug-overdose deaths—the vast majority involving at least one opioid—has climbed from a hundred and twenty-seven, in 2010, to three hundred and forty-nine, in 2016.

The epidemic shows no sign of abating, not least because the opioid that is now most commonly detected in postmortems is fentanyl, which is nearly forty times more potent than heroin. Depicted here is a sample of carfentanil, which is ten thousand times more potent than morphine. Its official use is for sedating large zoo animals; just two milligrams of the drug can tranquillize a two-thousand-pound elephant.

After a dose of Narcan has been administered, first responders inject normal saline. Here, a young man is given saline after receiving twenty-two milligrams, or eleven hits, of Narcan.

The body of someone who has died from a suspected opioid overdose. In January, 2017, there were sixty-five overdose deaths in Montgomery County. At times, there has not been enough room at the morgue for all the bodies, and the county coroner has been obliged to rent space from local funeral homes and lease refrigerated trailers for more space.

Brian Malmsbury’s death was an especially quiet one. He was thirty-three and had been living at home, in Miamisburg, Ohio, trying to get clean after years of addiction.

His mother, Patty Neff, said that he often fantasized about becoming a long-distance truck driver—being out on the road, just him and his dog. But his history with drugs made that an unlikely path forward. He had dealt with depression for many years—“He’d always just been a sad kid,” Patty told Philip Montgomery, the photographer who shot these images.

On the afternoon that Brian died, he had been talking to his mother about meeting a friend, and she and his stepfather thought that he’d gone out. But he’d headed down to the basement, where he overdosed on heroin and died. His stepfather, Damian Neff, found him there a day and a half later.

In recent years, Brian’s girlfriend had died of an overdose, and so had his younger sister’s boyfriend. “I didn’t think it could get any closer to our family after it took those two,” Patty Neff said. “And it does get closer. The boys would tell me every day about somebody they went to high school with who died that day. That whole generation’s getting wiped out.”